Intake Form
NAME: ___________________________________________________
Address:
City:
Postal Code:
Birth Date: (mm/dd/yy)
Occupation:
Home Phone:
Work Phone:
Cell Phone:
E-Mail:
OK to contact via E-Mail: yes/no
Employer:
Family Doctor:
Doctor’s Phone #:
Are you here as a result of a Motor Vehicle Accident?
(If yes) Name of Insurance Company:
Name of Insurance Contact Person (adjustor) :
Date of Accident:
Claim Number:
Do you have private medical coverage?
Name of Company:
Policy/Plan Number:
Percentage Covered:
YES NO
YES NO
ID Number:
To Maximum of:
How did you hear about us?__________________________________________________
Medications:_______________________________________________________________
Past Surgeries or Injuries:
_________________________
_________________________
_________________________
Date:
_________
_________
_________
Treatment Received:
_________________
_________________
_________________
Current or Past Therapy received (please circle): Chiropractic, Physiotherapy,
Massage Therapy, Acupuncture, Homeopathic, Cranio-Sacral Therapy, Podiatry
Other:___________________
Water Intake: ____ cups/day
Caffeine Intake:_____ cups/day
Please Note: MSI/Medicare does not cover Private Physiotherapy or Massage Therapy in Nova Scotia Therefore,
you are directly responsible for payment of services provided. Payment must be made after each session. A receipt
will be issued at that time for submission to your Insurance Company. Your time is reserved for you. Should you
need to cancel an appointment, a minimum of 24 hours notice is required. Otherwise you will be billed for half the
price of the scheduled appointment.
Signature:_________________________________
Date_____________________
Please indicate any of the following conditions that you have:
__Arthritis
__Diabetes
__Thyroid Condition
__Dizziness/Fainting
__Low/High Blood Pressure
__Heart Condition
__Chest Pain
__Pace Maker
__History of Cancer
__Allergies
__Epilepsy/Seizures
__Shortness of Breath
__Asthma
__Bronchitis
__Hearing Impairment
__Pregnancy
__Metal Implants (Incl IUD)
__Loss of Sensation
__HIV/AIDS
__Headaches/Migraines
__Hernia
__Depression
__Osteoporosis
__Smoking History
__Raynauds
__Sleeping Problems
__Cough
__Vision Difficulties
__Swallowing Difficulties
__Slurred Speech
__Memory Problems
__Balance Problems
__Recent Falls/Blackouts
__Unexplained Weight Loss/Gain
__Bowel and Bladder Difficulties
__Varicose Veins
__Parkinson’s
__Multiple Sclerosis
__Blood Diseases
__Hepatitis
Please indicate any areas which you presently suffer pain or discomfort by shading in
that area on the diagram:
Consent to Treatment:
Signature:____________________________________ Date:_____________________